Medical Records - Alterations

We are often asked under what circumstances, and how medical records may be altered.  This article condenses advice from the Medical Defense Organisations and the GMC:

• Medical notes must never be overwritten or inked out, and computer records should not be completely deleted.
• Hard copy errors should be scored out with a single line, so that the original writing is still visible, and the correct entry should be written alongside, with the time and date and your signature.
• Any additions should be separately dated, timed and signed.
• If making an entry or correction to a computer record, ensure there is an audit trail identifying the date and time of the change and the person who made it.
• It should be immediately obvious that an amendment has been made.
• QoF codes form part of the record so need to be an accurate description of the patient’s condition or treatment.
• If you discover a factual error you should inform the patient and explain any implications for their health or treatment. Apologise and explain that the records will be amended. You may wish to add a note that you have explained the error to the patient.
• Occasionally, there may be circumstances, after a full risk assessment, that it may be agreed that information will be removed from a paper record.  this should be discuss with the patient and guidance sought from your Caldicott Guardian and/or MDO before making a decision.
• If you do not agree with a request for an amendment, you can explain to the patient that they may add a statement that they disagree with some part of the content.  If the patient is still unhappy, they may follow the normal complaints procedure or approach the Information Commissioner's Office.